Is Bi-level Positive Airway Pressure (BiPAP) therapy indicated for a patient with a small pneumothorax?

From the Guidelines

BiPAP should be withheld from patients with a small pneumothorax due to the risk of worsening the condition. The positive pressure ventilation from BiPAP can potentially worsen the pneumothorax by forcing more air into the pleural space, causing it to expand and potentially leading to tension pneumothorax, which is a medical emergency 1. For patients with respiratory distress and a known pneumothorax, alternative management strategies should be considered first, such as:

• Supplemental oxygen via nasal cannula or face mask
• Chest tube placement for pneumothorax drainage
• Mechanical ventilation with careful monitoring if absolutely necessary If BiPAP must be used in a patient with a small, stable pneumothorax due to severe respiratory failure with no other options, it should only be done with extreme caution, continuous monitoring, and preparation for immediate intervention. The underlying mechanism of concern is that positive pressure can create a one-way valve effect, where air enters the pleural space during inspiration but cannot escape during expiration, progressively increasing pleural pressure and compromising cardiopulmonary function. The risk-benefit ratio must be carefully assessed on an individual basis, considering the severity of respiratory failure against the risk of pneumothorax expansion, as recommended by the guidelines for managing pneumothorax in patients with cystic fibrosis and other severe obstructive airways diseases 1.

From the Research

Pneumothorax Management

• Pneumothorax is an urgent situation that requires immediate treatment upon diagnosis 2
• Small spontaneous pneumothoraces typically resolve without treatment and require only monitoring 2
• Management options for spontaneous pneumothoraces should be selected based primarily upon a patient's clinical status 3

Noninvasive Ventilation

• Noninvasive ventilation (NIV) provides respiratory support without the use of invasive ventilation 4
• Available NIV modes include bilevel positive airway pressure (BiPAP) 4
• There is no consensus among the use of NIV in trauma patients and ARDS, but it may be beneficial in other conditions such as acute exacerbation of COPD, cardiogenic pulmonary edema, and COVID-19 4

BiPAP in Pneumothorax

• There is limited evidence on the use of BiPAP in patients with small pneumothorax 2, 5, 6, 3, 4
• However, BiPAP may be considered as a noninvasive ventilation mode in patients with pneumothorax who require respiratory support 4